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Motivational Enhancement Therapy

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    Motivational Enhancement TherapyApproachThe MET approach comes in five strategies taken from Miller and Rollnick (1991).  The following are the main strategies used in the application of MET approach intended for adolescents:Expressing Empathy and AcceptanceCommunicating respect for the client is very important under MET treatment.  While this treatment approach is not based on confrontation, implications of a superior or inferior relationship between the client and the therapist are to be avoided.

      It is imperative that the therapist does not give the impression of trying to convince clients of the error of their ways but act as a supportive listener and a knowledgeable consultant.Seeing that MET treatment is much more on listening rather than telling, empathic listening and accurate reflection play a vital role in facilitating change.  Understanding and acceptance by the therapist is very important to adolescent clients so that they view therapist as consultant for their personal change process.The therapist expresses empathy to the ambivalence of the client’s thought on quitting marijuana use and at the same time reflects accurately to their mixed feelings through double-sided reflections.

    Developing DiscrepancyThe MET treatment helps clients in recognizing the discrepancy between the effects of cannabis abuse on their lives now and how they would like their lives to be.  By the time people realize and gain awareness of this discrepancy, motivation and desire for change occurs.  This treatment is not about conveying the client with a degrading impression of being a marijuana abuser.  It is about making them realize and reflect on how the client’s marijuana use interferes with goal attainment.

      Moreover, therapists have to listen for what is important to the client in the immediate future since most of marijuana-smoking adolescents do not have many expressed goals for their immediate future.Regardless of the fact that some adolescents are unable to verbalize any specific goals, they certainly have vague belief that quitting marijuana could change their lives for the better.  It is in this case that MET therapists are of great help in reflecting this positive expectation back to the client giving them chance to correct an inaccurate reflection and allowing them to feel better understood eventually.Avoiding ArgumentationDirect argumentation has the tendency of evoking resistance as the therapist and the client interact.

      The MET approach strictly avoids argument in proving or convincing the client.  According to Miller and Rollnick (1991), it is the client who will voice out the arguments for change and not the therapist in the MET session.  Clients usually become defensive or even hostile possibly due to the previous comments of the therapist.  This is a drift to a confrontational approach from a MET approach entailing the need for resuming the motivational interviewing style.

      Therapist should treat the client’s ambivalence as normal in order to avoid argumentation.  The use of double-sided reflections helps client to feel that they are understood, therefore, decreasing their defensiveness.Rolling with ResistanceThe MET approach deals with resistance through rolling with it rather than meeting it head on.  Rolling with resistance necessitates empathy in reflecting the client’s hesitancy to change.

      Otherwise, the client will likely to defend and further strengthen their opposition to change seeing that therapist responds with a counter argument.  Hence, rolling with resistance means letting the client know that it will be up to them to decide if and when to change.  Giving this freedom of decision to change sometimes provides more information for the client to decide whether smoking weed is a problem for them or not.  Giving assurance to the client that decisions about change are up to them will often make client become more open to looking at the issue with an open mind.

    Supporting Self-efficacyThe MET approach helps to develop and encourage the client’s belief that they can change successfully.  Most adolescent clients have this fear that they will not succeed of making change even though they admit that smoking weed is a problem.  In fact, people recognizing that they have serious problem are still unlikely to move toward change except when they know there is hope for success.  Developing and/or strengthening their sense of self-efficacy is very important to encourage the client that they can reduce or even stop using marijuana.

      The therapist will have to ask the client regarding previous successful experiences they have had in areas relevant to cannabis abuse like success in quitting other drugs or alcohol and control on problematic habits.  Though some clients may not make the connection between their previous accomplishments and the possibility of their success in quitting marijuana, it will certainly boost their self-efficacy to change.RationaleThe Motivational Enhancement Therapy approach begins with the assumption that the responsibility and capability for change lie within the client.  The task of the therapist is to create a set of conditions that will enhance the client’s own motivation for and commitment to change.

      Rather than relying upon therapy sessions as the primary locus of change, the therapist seeks to mobilize the client’s inner resources, as well as those inherent in the client’s natural helping relationships.  MET seeks to support the intrinsic motivation for change, which will lead the client to initiate, persists in, and comply with behavior change efforts.Process and StepsI.      Motivation Building1.

    Building Rapport and Treatment OrientationThis part of the treatment is very important since it is during this period that therapist and client first get to know each other and eventually will help client create the feeling that the therapy sessions will be safe and supportive.  This process is initiated by the therapist through an introduction of himself/herself along with a brief explanation of the purpose of the first meeting.In this phase, the therapist starts with some casual conversation and a review of demographic facts, and attempt to learn a bit more about the client.  In order to leave enough time for the remainder of the session, this discussion should be fairly general and brief.

      The therapist then asks an open-ended question on what led to the client’s involvement in marijuana treatment in initiating some of MET strategies for the treatment.Orientation to TreatmentThe therapist hands out a copy of orientation sheet to the client and summarizes the main points in order to introduce the client to the treatment.Reviewing Personal Feedback Review and Reacting to itThe Personalized Feedback Report (PFR) should be given by the therapist to the client.  The therapist and the client should have their own copies of the PFR to review together to increase the collaborative nature of this process.

      The PFR included in this manual illustrates all possible items that could appear on a PFR.  The client’s PFE will include some subset of the illustrated items, based on the client’s responses during the intake or research assessment.  The PFR is most useful for developing motivation when the client is given the opportunity to elaborate on each point.Sometimes clients may respond to the PFE review by attempting to argue about the validity of the items on their personal report.

      In such cases, therapist must not try to debate the client, instead, maintain a non-defensive tone and acknowledge that the client knows best what areas of his or her life have and have not been affected by marijuana use, and move on to the next item.Reviewing PFR is expected to take approximately thirty minutes.  This allows for quite a bit of discussion and related comments.  Use double-sided reflections, develop discrepancy, and employ other MET strategies where relevant.

      Reviewing the PFR provides an excellent opportunity to explore the client’s ambivalence and to begin developing motivation for change.  After reviewing the entire PFR, the therapist asks the client about his or her reactions to it, and listens with empathy.Session Summary and Preparation for Next SessionIn the final phase of the MET session, the therapist summarizes the main points heard from the client.  Then, the therapist asks the client about his or her readiness for change in a way not to pressure the client in doing so.

      Whether the client plans to quit or reduce marijuana use at this point, the therapist should tell the client that he or she will continue discussing this issue during the next session.  It is also important to ask the client on what today’s session has been like for him or her.  Lastly, the therapist sets up an appointment to meet again the following week.II.

          Goal-Setting1.      Progress ReviewThe therapist starts the review of treatment progress by asking the client how he or she has been doing over the past week regarding the marijuana issue.  The therapist should be prepared to listen for possible changes in the client’s behaviors, thoughts, and feelings regarding marijuana.  It is imperative that therapist responds with reflective comments and attempts to elicit the client’s own motivation-enhancing statements.

    2.      Goal-SettingThe therapist will summarize statements heard from the client that indicates motivation for change.  It is during this phase that the therapist explains to the client that having a written goal increases the likelihood that the rest of the therapy will be useful to him or her and that he or she will be more likely to succeed.3.

          Functional AnalysisIn this part, clients should be ready to examine the function of marijuana in their lives.  This helps clients to understand that marijuana use does not just happen but is rather a function of antecedents and consequences that is aimed at increasing the client’s awareness of those factors, providing better focus for the ensuing CBT interventions, and enabling better decision making on a daily basis.StudiesBy research, motivational enhancement therapy has shown to induce change in some other areas like alcohol problems.  Studies of Bien, Miller, and Tonigan (1993) have shown that therapeutic interventions containing some or all of motivational elements presented above have been demonstrated in over two dozen studies to be effective in initiating treatment, and in reducing long-term alcohol use, alcohol-related problems, and health consequences of drinking.

      The study Stephens and Roffman (1993) reported that motivational interviewing is effective with marijuana dependent adults. Cognitive Behavioral Therapy (Individual)ApproachThis treatment approach is based on a social learning model focusing on training clients in interpersonal and self-management skills.  In order for clients to master the skills needed to maintain long-term abstinence from marijuana, it is important that the client develops his or her identification of high-risk situations that may increase the likelihood of relapse.  These high-risk situations include external precipitants of using, as well as internal events such as cognitions and emotions.

    Seeing that such situations may create high risk for relapse, the client has the need to develop skills in coping with them.  All throughout the three CBT individualized sessions, the client is taught basic skill elements for dealing with common high-risk problem areas and is encouraged to engage in role-playing and real life practice exercises that will enable them to apply these skills to meet their own needs.In the CBT sessions, the client receives constructive feedback from the therapist using relevant problems that can build their skills.  Active practice with positive and corrective feedback is the most effective way to modify self-efficacy expectations and create long-lasting behavior change.

      CBT treatment also requires active participation from the client along with his or her assumption of responsibility for using the new self-control skills to prevent future abuse.  In a training program, active participation can replace an individual’s maladaptive habits into healthy behaviors regulated by cognitive processes that involve awareness and responsible planning.RationaleCognitive behavioral therapy is designed to remediate deficits in skills for coping with antecedents to marijuana use.  Individuals who rely primarily on marijuana to cope have little choice but to resort to substance use when the need to cope arises.

      The goal of this intervention is to provide some basic alternative skills to cope with situations that might otherwise lead to substance use.  Skill deficits are viewed as central to the relapse process; therefore, the major focus of the CBT groups will be on the development and rehearsal of skills.The cognitive behavioral paradigm assumes that thinking, feeling, and doing are separate realms of human process that become associated through learning.  Cannabis use, like any behavior, can be linked with thoughts, feelings, and other behaviors through direct experience or through observation.

      Associations can be strengthened by intense learning experiences or by placing certain thoughts, feelings, or actions in frequent proximity to use.  When they are strong enough, associations can even serve as triggers (i.e. antecedents) that effectively cue or reinforce a person’s desire (i.

    e. consequences) to use – even when that person is planning to abstain.  From a cognitive behavioral perspective, for individuals to change their patterns of cannabis use, they should attend to the context in which they use, as well as to the decisions that lead to using.  Taking a broad perspective on the context of cannabis use can improve one’s chances for anticipating and thereby avoiding unintended relapse.

    A second rationale in the cognitive behavioral framework is that teaching and consulting are appropriate ways of intervening with people who have mental health problems.  As teachers, cognitive behavioral therapists use a classroom teaching style to help clients comprehend coping skills.  They use experiential teaching methods to help clients internalize coping skills that are personally useful.  As consultants, therapists tailor session content to problems raised by an individual or by group members.

      The cognitive behavioral therapist is not perceived as an expert by the client but rather as an ally who appreciates the difficulty of balancing personal emotions and ambiguous social demands and who is prepared to share ideas about how to deal with both.Process and StepsIII.      Marijuana Refusal Skills1.      Introduction and Brief Review of ProgressThe first part of the session is the client’s introduction along with a brief review of his or her progress.

    2.      Review of Real Life PracticeThe therapist will ask the client for his or her self-monitoring records to pick one episode that he or she wrote and share it with the therapist.3.      Marijuana Refusal SkillsThe therapist sets out the verbal and non-verbal behaviors for refusing marijuana and applies these skills into practice through role-playing.

    IV.      Enhancing the Social Support Network and Increasing Pleasant Activities1.      Progress ReviewThis part of the session requires clients to provide urine samples for drug testing.  After obtaining urine samples, the therapist should start with question about the client’s recent progress.

    2.      Review of Real Life Practice ExerciseThe therapist asks the client about his or her real life practice exercise on refusing marijuana.  The therapist allows the client to read his or her responses to the refusal skills real life practice exercise.3.

          Enhancing Support and Increasing Pleasant ActivitiesIn this phase, the therapist reviews the rationale for increasing support and the role of enjoyable activities in quitting marijuana.V.      Planning for Emergencies and Coping with Relapse1.      Progress ReviewDuring this phase, the client offers to communicate the results of the client’s urine tests for drugs taken from the previous meeting.

    2.      Review of Real Life PracticeThe therapist asks the client about their responses to the seeking and giving support practice exercise and reinforces the client’s attempt to try out the enhancing social support network skills through real life practice.3.      Planning for Emergencies and Coping with RelapseThe therapist asks the client about the types of emergencies that he or she may encounter and writes down the client’s responses.

    4.      TerminationThis is the final part of the entire MET/CBT-5 set aside for a discussion of termination of therapy.  The therapist asks the client what it has been like throughout the sessions and gives positive and supportive feedbacks to the client’s answers.  At this point, the therapist asks the client about his or her goals regarding marijuana.

    StudiesIn clinical trials, cognitive behavioral approaches to treatment have been demonstrably effective with other behavior-and motor-related problems experienced in childhood and adolescence, as well as for relapse problems of adult substance abusers.Cognitive behavioral interventions are helpful to children and adolescents with behavior or mood problems and those with conduct disorder or subclinical delinquency.  Cognitive behavioral trials with this population have yielded improvements in problem solving, self-control, prosocial behaviors, and positive communication that have been sustained for at least a year (Kazdin et al., 1989).

    Trials with children and adolescents diagnosed with attention deficit/hyperactivity disorder (ADHD) have been less successful.  Although these trials yield temporary improvements for on-task behavior and self-control, the effects often last less than a year.  The treatment effects also do not generalize to social situations and do not enhance the effects of medication (Kendall & Wilcox, 1980; Douglas et al., 1976).

    With respect to internalizing disorders, cognitive behavioral interventions appear effective with adolescents who meet the criteria for having depressive disorders.  Not uncommonly, reduced rates of depression and relapse are sustained within these populations for at least 2 years (Hops & Lewinsohn, 1995).Another type of client that seems to benefit from cognitive behavioral treatment is the adult aftercare recipient in recovery from a substance use disorder.  For this population, the cognitive behavioral paradigm appears to be a useful educational method for helping to organize and anticipate stages of relapse.

      Of particular relevance to this manual is Marlatt and Gordon’s (1985) cognitive behavioral model of relapse.  Marlatt and Gordon propose that relapse is a sequence of stages that can be arrested when appropriate cognitive behavioral techniques are introduced to halt the progress from one stage to the next.  According to their stage model, triggers that generate cravings for a substance work synergistically with positive thoughts about a substance’s satisfying effects to undermine resistance.  By using self-talk and social support to check cravings and by mentally challenging the perceived benefits of use, adult aftercare patients can effectively prevent relapse and extend periods of abstinence.

    Based on its success rate with children and adolescents with a variety of behavior or mood problems and with substance abusers, CBT was selected as an appropriate component of treatment for participants in the cannabis youth treatment study.  ReferencesBien, T. H., Miller, W.

    R., & Tonigan, J. S. (1993).

    Brief interventions for alcohol problems: A review. Addiction, 88, 305–325.Douglas, V.I.

    et al. (1976). Assessment of a cognitive training program for hyperactive children. Journal of Abnormal Child Psychology, 4, pp.

    389-410.Hops, H. & Lewinsohn, P. (1995).

    A course for the treatment of depression among adolescents. In D. Craig & K. Dobson (eds.

    ), Anxiety and depression in adults and children (pp. 230-245). Thousand Oaks, CA: Sage Publications, Inc.Kazdein, A.

    E. et al. (1989). Cognitive-behavioral therapy and relationship therapy in the treatment of children referred for antisocial behavior.

    Journal of Consulting and Clinical Psychology, 57, pp. 522-535.Kendall, P.C.

    & Wilcox, L.E. (1980). A cognitive-behavioral treatment for impulsivity: Concrete vs.

    conceptual training in non-self-controlled problem children. Journal of Consulting and Clinical Psychology, 47, pp. 1020-1029.Marlatt, G.

    A., & Gordon, J. R. (Eds.

    ). (1985). Relapse prevention. New York: Guilford.

    Miller, W. R., & Rollnick, S. (1991).

    Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford.Stephens, R. S.

    , & Roffman, R. A. (1996). Treating adult marijuana dependence.

    Marijuana use: Basic mechanisms, epidemiology, natural history, and clinical issues. A symposium conducted at the Fifty-Eighth Annual Scientific Meeting of the College on Problems of Drug Dependence, San Juan, Puerto Rico.  

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